Thursday, November 30, 2017

If legislation harmful to health was required to carry a
Surgeon’s General warning like tobacco, the tax bill being voted on today by
the Senate would surely qualify.It will
harm health care for many millions of Americans, leading to more uninsured
persons and higher premiums.It also
will lead to automatic scheduled cuts to Medicare and many other programs that
are vital to health care.Yet despite
all of this, the Senate is poised to vote later today on the Tax Cuts and Jobs
Act, and right now, it looks more likely than not it will pass the chamber by a
party-line, Republican only majority vote (all Democrats are expected to vote
against it).

Here are 2 things you need to know about the bill and how it
will hurt patients and their doctors:

1.By repealing the Affordable Care Act (ACA)
requirement that people purchase a qualified health insurance plan or pay a
penalty to the government, people who buy coverage in the individual insurance
market will see double-digit premium increases, many insurers will bolt from the
markets resulting in less competition and choice, and 13 million people will
become uninsured. The individual insurance requirement is needed because
without it, many people will wait until they get sick to enroll in coverage,
knowing that the ACA prohibits insurers from charging sick people more.With more sick people and fewer healthy
people in the insurance pool, insurers will have no choice but to jack up
premiums for everyone, or simply, decide not to see insurance at all in the
individual market.The American Academy
of Actuaries has warned
that repeal of the individual mandate would lead to premium increases, weaken
insurer solvency, cause an increase in insurer withdrawals from the market, and "lead to severe market disruption and loss of coverage among individual market
enrollees." According to a report
by the non-partisan Congressional Budget Office, repealing the individual
mandate would increase the number of uninsured by four million in 2019 and 13
million in 2027 and "average premiums in the non-group market would increase by
about 10 percent in most years of the decade."

2.Medicare and other vital health care
programs will be cut by billions of dollars to pay for the tax cuts that go
mainly to corporations.Under a 2010
law called Statutory Pay-As-You-Go Act (SPAYGO), any law that will add to the
federal deficit must be paid for with spending cuts, increases in revenue or
other offsets.Automatic cuts are
imposed, through budget sequestration, if Congress does not enact the required
offsets.The Senate tax bill is projected
to increase the federal deficit by $1.5 trillion over the next 10 years, so
automatic across-the-board cuts will be triggered next year unless Congress
passes separate bills to offset the cost in some other way.Medicare would be automatically cut by $25
billion in 2018, which will result in an average cut of 4 percent in Medicare
payments for health care services provided bydoctors, hospitals, clinical laboratories, graduate medical education
programs, and other "providers."For
doctors, this cut will be on top of a near 3 percent cut that Congress
previously imposed on them in 2013, 14, 15, 16, and 17—combined, Medicare
payments to physicians will have been cut 7 percent less as a result.Many other vital health programs, like the
Centers for Disease Control and Prevention (which we all count on to help
prevent infectious diseases, whether it is this year’ seasonal flu, or global
pandemics that could sicken millions worldwide), will also be subjected to
deep, across-the-board spending cuts to pay for the tax bill; some will be
completely eliminated.The New York
Times has a very useful list and graphic of what will be cut, and by how much.

Is it any wonder then that the American College of
Physicians, the nation’s largest physician specialty society, and second
largest physician membership organization, came out today in opposition to the Senate bill?

Should the Senator ignore ACP’s advice and pass the bill, it
doesn’t mean that the fight is over, since the Senate would have reach an
agreement on a identical tax bill that both chambers could support (the House
passed its own, but different version, several weeks ago).But any Senator who votes for Tax Cuts and
Jobs Act must be held accountable by their constituents forvoting for a bill that is bad for their
health, while disregarding doctors’ warnings about the harm it will do.

Tuesday, October 31, 2017

The Centers for Medicare and Medicaid Services’ (CMS) new
initiative to reduce the paperwork burden on doctors and patients, deemed Patients Over Paperwork, is remarkably similar to ACP’s campaign, called Patients
Before Paperwork, to
accomplish the same. Whether the agency was directly inspired by
ACP’s campaign, down to coming up with an almost identical name for it, or came
up with a similar moniker on its own, what matters is that the message ACP has
been pushing for more than two years now, that doctors are being squeezed by
unnecessary administrative tasks that take time away from patients, is being
heard now at the highest reaches of the federal government. What I do know is that prior to CMS’ launch
of the initiative last week, ACP has held several meetings with and previously
wrote to CMS officials pressing our recommendations to reduce unnecessary
regulations and other administrative tasks.

In her
remarks yesterday to the Health Care Learning and Action Network Fall
Summit, CMS Administrator Seema Verma explained what CMS hopes to accomplish
from Patients Over Paperwork:

Since assuming my role at CMS, we
are moving the agency to focus on patients first. To do this, one of our top
priorities is to ease regulatory burden that is destroying the doctor-patient
relationship. We want doctors to be able to deliver the best quality care to their
patients.

We often hear about this term –
“regulatory burden” – but what does it actually mean? Regulations have
their place and are important to ensuring quality, integrity, and safety in our
health care system. But, if rules are misguided, outdated, or are too complex,
they can have a suffocating effect on health care delivery by shifting the
focus of providers away from the patient and toward unnecessary paperwork, and
ultimately increase the cost of care.

I saw this during a recent trip to
Hartford, Connecticut, where I met with providers.

One told me
she was going to close her practice after decades in medicine because spending
so much time away from her patients doing paperwork just wasn’t worth it for
her anymore.

In Cleveland, Ohio, I heard a story
of a physician who was overwhelmed by having to personally fax patient
records…in 2017 we are still faxing patient records. Just thinking about that
frustrates me…having to do it, I’m sure is even worse.

Doctors are frustrated because they
got into medicine to help their patients. But, paperwork has distracted them
from caring for their patients, who often have waited weeks, if not months, for
the brief opportunity to see them.

We have all felt this squeeze in
the doctor’s office…we have all seen our doctors looking at a computer screen
instead of us. I hear it from patients across the country. This must change.

The primary focus of a patient
visit must be the patient. Just last week, CMS announced our new
initiative “Patients Over Paperwork” to address regulatory burden. This is an
effort to go through all of our regulations to reduce burden. Because when
burdensome regulations no longer advance the goal of patients first, we must
improve or eliminate them.

At CMS, our overall vision is to
reinvent the agency to put patients first. We want to partner with patients,
providers, payers, and others to achieve this goal. We aim to be responsive to
the needs of those we serve. We can’t do that if we’re simply telling our
partners what to do—instead of listening and—most importantly—having our
policies be guided by those on the

front lines serving patients.

Touche! ACP couldn’t
have said it better. Today, we sent a letter
to Administrator Verma to pledge our support for her Patients Over Paperwork initiative. We shared with her our
policy paper, Putting
Patients First By Reducing Administrative Tasks in Health Care, which
proposes an entirely new framework to evaluate the intent and impact of
existing or proposed new tasks, so that those that are not justified by their
intent, or that have such an adverse impact on doctors and patients that they
cannot be justified even if the original intent is sound, can be challenged and
then eliminated or at least ameliorated.
We urged that CMS adopt this framework to evaluate its own regulations
and administrative tasks.

ACP’s letter also advised her that we were encouraged by her
announcement of a new “Meaningful Measures” initiative to ensure that quality
measures, which are a critical component of paying for value, are streamlined,
outcomes-based, and truly meaningful to clinicians and their patients. This initiative appears to be well aligned
with ACP's comments
to CMS last year on the Quality Measure Development Plan.

Whether it is putting patients before or above
paperwork—both are needed—it is great news for doctors that ACP’s two-year plus
campaign to reduce administrative tasks on physicians has found support in the
highest reaches of government, coming from the head of an agency, CMS, that can
do more to ease red tape than any other.

Today’s question: if you were CMS Administrator Verma, what
is the first Medicare administrative task you would recommend she review?

Directly affected by the decision are Dreamers enrolled in
U.S. medical schools. “According to the
Association of American Medical Colleges, in 2016, 108 students with DACA
status applied to medical school, and 34 matriculants with DACA status entered
medical school, bringing total medical school enrollment to approximately 70
students,” ACP noted in its statement. “Without the protections afforded to
them by DACA, these students would be forced to discontinue their studies and
may be deported. As these students train to become physicians, they will have
the experience and background necessary to treat an increasingly racially and
ethnically diverse patient population to fulfill the cultural, informational,
and linguistic needs of their patients…”
Also affected are Dreamers “studying to be nurses, first-responders,
scientists, and researchers, and approximately 1,000 foreign-born recruits who
enlisted in the military under the protections offered by DACA could face
deportation, according to the Washington
Post.”

Public health will also be adversely affected, according to
ACP. “If the nearly 800,000 people who are currently benefiting from DACA have
their protections removed, many will avoid seeking health care in order to
reduce the risk of detection and deportation, and as noted above, those who
seek to serve in the health care professions will be denied that
opportunity. Many will be forced to
return to violent, war-torn and dangerous countries with poor health care
services.”

That the President will delay full enforcement of his
decision to end DACA “in no way mitigates the harm that will be done to the
800,000 law-abiding persons who have achieved permits under DACA to work or
study in the United States without fear of deportation” said ACP. “They are now
at risk of losing their jobs, being forced to drop out of school, and being
deported in just a matter of months.”

ACP called on President Trump to reverse his decision and
continue protections for those with DACA-status—even though there is virtually
no chance that he will. More likely,
Congress will need to act, by enacting legislation to block the deportation of
Dreamers and to create a pathway for citizenship, as proposed by S. 128, the
Bar Removal of Individuals who Dream and Grow our Economy (BRIDGE) Act, and S.
1615, the DREAM Act of 2017.

ACP’s decision to stand up for Dreamers reflects our
long-standing commitment to creating a national immigration policy that
recognizes the enormous contributions that immigrants make to the United
States, and to health care in particular.
In 2011, ACP
issued a policy paper that called “for a national immigration policy on health
care that balances legitimate needs and concerns to control our borders and to
equitably differentiate in publicly supported services for those who fully
comply with immigration laws and those who do not, while recognizing that
society has a public health interest in ensuring that all resident persons have
access to health care.” Further, ACP
asserted in this paper that “Any policy intended to force the millions of
persons who now reside unlawfully in the U.S. to return to their countries of
origin through arrest, detention, and mass deportation could result in severe
health care consequences for affected persons and their family members
(including those who are lawful residents but who reside in a household with
unlawful residents— such as U.S.-born children whose parents are not legal
residents), creates a public health emergency, results in enormous costs to the
health care system of treating such persons (including the costs associated
with correctional health care during periods of detention), and is likely to
lead to racial and ethnic profiling and discrimination.”

On January 30 of this year, ACP’s
Board of Regents released a comprehensive statement on immigration policy,
expanding on the 2011 paper, which “strongly opposes discrimination based on
religion, race, gender or gender identity, or sexual orientation in decisions
on who shall be legally admitted to the United States as a gross violation of
human rights.” Based on this policy, ACP
has opposed President Trump’s executive orders to bar persons from several
majority Muslim countries from entering the United States.

ACP also said that “Priority should be given to supporting
families in all policies relating to immigration and lawful admission to the
United States to live, study, or work.”
Accordingly, “ACP opposes deportation of undocumented medical students, residents, fellows,
practicing physicians, and others who came to the United States as children due
to the actions of their parents (‘Dreamers’) and have or are eligible for
Deferred Action for Childhood Arrivals (DACA) status. We urge the
administration to preserve the DACA action taken by the previous administration
until such time that Congress approves a permanent fix. The College also urges
Congress to promptly enact legislation to establish a path to legal immigration
status for these individuals to ensure that ‘Dreamers’ are permanently
protected from deportation.”

For ACP, concern about immigration policy and its impact on
health care clearly is nothing new. What
is new, regrettably, is that the current administration has chosen to embrace
immigration policies that are discriminatory against persons based on their
religion and country of origin, threaten to split up families that have members
here both lawfully and unlawfully, make
it less likely that immigrants who lack legal residency will access needed
health care services, and now, threaten with the deportation of Dreamers, who
for all practical purposes, are as American as the rest of us, having lived
almost their entire lives in the United States, and who stand to contribute so
much to our country if the country has the wisdom to welcome them.

This is why it is more important than ever that doctors
defend Dreamers, and others who would be harmed by the current administration’s
ill-advised immigration policies.

Today’s question: what do you think of ACP’s response to
President Trump’s decision to discontinue DACA?

Thursday, August 10, 2017

While many people contributed to the defeat of the current
efforts by Congress to repeal the Affordable Care Act (ACA), physicians had a
big role in organizing opposition to repeal, individually and collectively
through their professional societies—including through the American College of
Physicians.It was a redemptive moment
for American medicine, making up in part for its sad, sorry history of opposing
health insurance for all.

It is sobering to review the medical profession’s century-long
history of being unyielding opponents of universal coverage. To put a finer point on it, it was organized medicine—mainly the American
Medical Association (AMA) and state medical societies—that opposed universal
coverage or even partial steps toward it, since specialty societies for the
most part were not involved in advocacy until the 1970s or later.Even when the specialties began to take on
advocacy, they mostly addressed narrow issues that directly affected their own
disciplines. This left the AMA and the state medical societies to speak for
doctors on issues like access and coverage.

In 1920, the AMA’s House of Delegates officially came out
against what was called “compulsory health insurance” which “was viewed as a
threat to professionalism itself, requiring acceptance of mandatory fee
schedules, work reviews, organizations outside the doctor-patient relationship
over which doctors have no control; and limits on patient choice of physician,”
wrote Rosemary Stevens in her insightful book American
Medicine and the Public Interest, originally published in 1971 and
updated in 1998.

The AMA’s opposition to universal coverage was so powerful
that President Franklin Roosevelt did not include national health insurance
with the recommendations that formed the basis of the Social Security Act of
1935 because “he feared, probably correctly, that because health insurance had
such strong opposition from physicians [namely, the AMA] and others, if it were
included in his program for economic security, he might lose the entire program,”
wrote Robert M. Ball, in “Reflections on How Medicare Came About” in Medicare:
Preparing for the Challenges of the 21st Century. Ball ran the Social
Security program from 1962 to 1973, and he helped design Medicare for the
Johnson administration.

When President Harry S. Truman advocated for national health
insurance in 1948, “the AMA’s opposition approached hysteria,” Ball continued, noting
that the AMA raised a “$3.5 million war chest—very big money for the time—with
which it conducted a campaign of vituperation against the advocates of national
health insurance.”

In the early 1960s, the AMA vehemently opposed the enactment
of Medicare, even though Medicare as originally proposed by the Kennedy and
Johnson administrations would have applied only to hospital services (coverage
for physician services through the voluntary Medicare Part B program was added
late in the process at the request of Congressman Wilbur Mills, the
then-chairman of the Ways and Means Committee).“If physician services were left out entirely, we reasoned, the AMA’s
opposition would have less standing,” Ball wrote.“By that time it was clear that the elderly
had the most political appeal and potentially the most muscle.We wanted to get
something going, and this seemed a plausible first step.”The AMA also opposed Medicaid, the sister
program to provide coverage to some categories of poor women and children.

Although the AMA lost its fight against Medicare and
Medicaid, both of which were signed into law by President Johnson on July 30,
1965, it continued to resist most efforts to expand the government’s role in
health care through the 1970s and 80s. By the 1990s though, the AMA had
tempered its views, and while it never got behind President Clinton’s failed
Health Security Act, it also was no longer an unyielding opponent.The AMA even put its support behind programs
to incrementally expand coverage, including the Children’s Health Insurance
Program enacted in 1998.

This brings us to Obamacare. The AMA engaged constructively
with President Obama and the congressional leadership on the Affordable Care
Act, offering its qualified support for the bill leading up to its enactment in
March, 2010. And, the AMA opposes the current efforts by President Trump and
the GOP-controlled Congress to repeal and replace Obamacare with something that
would cover fewer people and offer less protection for people with preexisting
conditions.A sign of how much things
have changed for the AMA is when its House of Delegates in June of this year resoundingly
voted to oppose any legislative proposals to cap Medicaid—in
other words, to keep it an open-ended entitlement program.This is not your grandfather’s AMA, for sure.

The AMA’s evolution to supporting some variations of
universal coverage is welcome and necessary. Its speaking out against the
current efforts to repeal the ACA should be applauded.Yet, it also must be acknowledged that many
other physician organizations, representing even more doctors than the AMA can
now claim as members, have made it their mission and their passion to advocate
for universal coverage and against ACP repeal.

I am particularly proud of the ACP’s leadership.The ACP first came out for universal coverage
in the 1990s, gave qualified support to President Bill Clinton’s Health
Security Act, and became a leading advocate during President Obama’s
administration for what became the Affordable Care Act.But the current efforts by President Trump
and the GOP-controlled Congress to repeal the ACA really tested ACP’s
mettle.And the College passed the test,
with flying colors.

ACP helped organize and lead a coalition of six front-line
physician membership organizations—the American College of Physicians, American
Academy of Family Physicians, American Academy of Pediatrics, American Congress
of Obstetricians and Gynecologists, American Osteopathic Association, and
American Psychiatric Association—to advocate for preserving coverage and
opposing efforts to repeal and replace the ACA with alternatives that would
leave millions more without health insurance. Collectively, the coalition
represents over 560,000 physician and medical student members, the vast
majority of front-line physicians in the United States. The six allied groups
above have conducted 5 separate fly-ins (2-2-17, 3-7-17, 5-11-17, 6-28-17,
7-12-17) involving the leadership of those six front-line physician
organizations, the most recent one was July 12.Meetings were held with targeted representatives and senators. 100
letters were hand delivered on June 28 to all Senate offices, signed by the
group of six, containing state-specific data on the harmful impact of the
Senate’s Better Care Reconciliation Act in each state.

ACP, on its own, sent at least 36 action alerts to our
grassroots network across the country, which includes targeted alerts to key
House members and senators; conducted a “write to Congress” letter-writing
campaign for all of our 50 chapter governors during our March Board of
Governors meeting; launched 7 separate full-scale action campaigns for our 50
chapters that also involved targeted campaigns for 8-10 states with Republican
senators who had expressed concerns about the repeal bills; sent 15 ACP
National letters to Congress; sent 14 coalition letters to Congress; had 3 TV
appearances on MSNBC, on “the Last Word” and with Kate Snow; sent 28 ACP and/or
joint releases/statements on repeal efforts;conducted local TV interviews that reached 16.2 million people with 549
airings of the content; and organized a social media campaign (including
through my @BobDohertyACP
twitter account) to organize opposition to repeal.And this is only a partial list of our
efforts! You can learn more about ACP’s activities on our website.

Our efforts, and those of so many others, paid off in the
wee hours of July 28 when Senator John McCain joined Senators Susan Collins and
Lisa Murkowski to cast their votes against Majority Leader McConnell’s last
ditch effort to get repeal through the Senate.

That ACP, our sister coalition partners, today’s AMA,
Doctors for America, the National Physicians Alliance, and many other
organizations representing physicians, have done so much now to save coverage
and access for millions cannot completely make up for a century of doctors
failing their patients by opposing Medicare, Medicaid, and universal coverage.
It doesn’t change the fact that there is a strong minority of physicians today
who continue to believe, like the AMA in 1920, that universal coverage is “a
threat to professionalism itself, requiring acceptance of mandatory fee
schedules, work reviews, organizations outside the doctor-patient relationship
over which doctors have no control; and limits on patient choice of physician”—one
of whom, Dr. Tom Price, is now Secretary of the Department of Health and Human
Services;every current Republican physician
who serves in Congress today holds similar views. It doesn’t change the fact
that many other physician membership organizations were missing-in-action in
opposing the current efforts to repeal coverage for millions, including most of
the surgical specialty societies and many of the state medical societies. So
yes, too many physicians today still hold views that led their predecessors to
oppose every reasonable effort by the government to extend coverage to
everyone.

But a much larger majority of physicians today have taken a
stand for coverage, for their patients, and against efforts to take it away
from them. Nothing can change history, when that was not the case, but it is
redemptive to see the medical profession today do the right thing by their patients.

Today’s question: What do you think of the medical
profession’s century-long history of opposing universal coverage, and the
efforts by many physicians today to stand up for coverage and against ACA
repeal?

Friday, June 23, 2017

President Trump told a group of Republican Senators that the House-based American Health Care Act is
“mean”—and on this he surely called it right! How else would one describe a
bill that would take health insurance away from 23 million people, allow states
to waive rules requiring insurers to cover people with preexisting conditions
at no extra charge, and raise premiums and deductibles to the oldest and
sickest patients. He reportedly urged
the Senate to come up with a bill that has more “heart.”

Well, if that was his pitch, the draft bill released
yesterday by Majority Leader Mitch McConnell is anything but. It’s heartless and harmful to the most
vulnerable in America: women, children,
the disabled, the elderly, the sick and the poor; to people suffering from
opioid addiction; and especially to the more than 70 million Americans who rely
on Medicaid for coverage and access to health care. Yet the President tweeted this morning in
favor of the bill. Go figure.

In fact, in many respects, the Senate bill, introduced under
the Orwellian name “The Better Care Reconciliation Act” (BCRA) of 2017, is
meaner and has even less heart than the House bill. It cuts Medicaid by more than the House
bill. It allows states to waive almost
all of the protections mandated by the ACA, including coverage for essential
benefits (like chemotherapy and treatment for opioid use disorders) and the
requirement that insurers spend at least 80 percent of their premiums on
patient care services rather than administration and CEO compensation (and it
even lifts the $500,000 cap on the amount that an insurer can deduct from taxes
for CEO compensation!). You can read
about all of the things that are heartless and harmful in the bill in a letter ACP sent yesterday expressing our strongest possible
opposition to it.

Yet Majority Leader
McConnell plans to bring it to a vote next week, before Congress adjourns for
an Independence Day recess, even though the bill was developed in secret, with
no hearings, no committee “mark-ups,” and with no effort to consider the views of
ACP and others who actually know something about how a lack of insurance
affects patient care. We won’t know the
Congressional Budget Office’s assessment of what the bill would cost, and how
many would lose coverage, until just hours before the bill will be voted on.

And make no mistake about it: the bill will pass the Senate
unless three Republican Senators have the moral courage to say no to it, and if
the Senate passes it, the House almost assuredly will do the same. Game over.

But we can still win this fight, but only if enough of you,
the constituents who your Senators are supposed to represent, speak out now about the harm it will do to
patients. Today, ACP issued an
all-hands-on-deck legislative alert to our Advocates for Internal Medicine, and linked to it in today’s ACPAdvocate newsletter sent to all ACP members. It has simple instructions and a sample
script to use in making your calls. We
especially need calls to the following Senators: Susan Collins (ME), Lisa
Murkowski (AK), Rob Portman (OH), Dean Heller (NV), Dan Sullivan (AK), Jeff
Flake (AZ), Cory Gardner (CO), Bob Corker (TN), Bill Cassidy (LA), and Shelley
Moore Capito (WV).

Next Wednesday, which may very well be the day before the
bill will be voted on in the Senate, ACP’s President will fly to Washington to
join with his counterparts with the American Academy of Family Physicians,
American Academy of Pediatrics, American Congress of Obstetrics and Gynecology,
American Psychiatric Association, and American Osteopathic Association to deliver
personalized letter to all 100 U.S. Senators urging a NO vote on the bill, on
behalf of the 560,000 physician and medical student members collectively
represented by our organizations, and their millions of patients. (Read the coalition’s statement on the Senate bill issued yesterday).

We are doing everything in our power to stop the Senate’s
heartless and harmful bill from becoming law.
Please help us, and more importantly your patients, by calling your
Senators now, 202-261-4530.

Tuesday, May 16, 2017

It’s been a long-held truism among conservatives that many
of those who live in poverty in the United States are undeserving of help,
because, well, it’s their own fault. If
they lived more virtuous lifestyles, studied and worked harder, and of course
got a good paying job, they wouldn’t be poor. And if they don’t do these things,
the thinking goes, then there is no obligation for “virtuous” taxpayers
(well-off people with good jobs) to help support them through publicly funded
poverty and income-transfer programs.

(Never mind that people can be poor
because there aren’t good schools where they live, or that well-paying factory
and other semi-skilled jobs are a thing of the past, or that there isn’t
accessible and affordable transportation to where the jobs are located, or that
we’ve had decades of income stagnation, or that minimum wages have not kept
pace with costs, or that their housing is substandard and their drinking water
unsafe, or that labor unions are no longer around to negotiate for better wages
and benefits, or that their parents and their parents before them were poor, so
they likely will be as well—it’s all their fault, tough luck. Or
that the so-called virtuous and well-off people with good jobs and incomes have
benefited from decades of income transfers from the poor to the rich, from
living in good and safe communities with good schools and good jobs, from
having nice cars to get them around from
their very nice houses to their very nice offices, even if it means sitting in
traffic for 45 minutes, or that their parents were well-off people who gave
them every advantage to get ahead—it’s all because of their virtue and
hard-work, no luck involved).

As offensive and factually wrong the “undeserving poor”
narrative is, there is a variation of it that is now coming to the fore in the
health care debate that may be even more offensive and wrong-headed, if that’s
even possible, which is that people are sick because of their own bad choices and
shouldn’t expect to get taxpayer-funded health care. This undeserving
sick narrative was used by President
Trump’s budget director, Mick Mulvaney, to defend the American Health Care Act
(AHCA) against late night TV host Jimmy Kimmel’s charge that the AHCA would
deny care to children, like his own newborn, born with a congenital heart
defect:

“The phrase ‘Jimmy Kimmel test’
was coined by Sen. Bill Cassidy, R-La., after Kimmel
delivered a monologue last week in which he shared difficult circumstances
about his son's birth and pleaded for politicians to keep Obamacare's guarantee
for coverage of people with pre-existing illnesses. Cassidy said he would vote
for a healthcare bill only if it met that test, and Mulvaney was asked by a
member of the audience at the Light Forum at Stanford University in Palo Alto,
Calif., if he agreed with that standard.

"‘I do think it should meet
that test,’ Mulvaney said. ‘We have plenty of money to deal with that. We have
plenty of money to provide that safety net so that if you get cancer you don't
end up broke…that is not the question. The question is, who is responsible for
your ordinary healthcare? You or somebody else?’

He said the debate centered on
whether others should pay the burden of paying for someone's healthcare. "That
doesn't mean we should take care of the person who sits at home, eats poorly
and gets diabetes. Is that the same thing as Jimmy Kimmel's kid? I don't think
that it is.’" [Emphasis added in italics].

Then there is Alabama Republican Rep. Mo Brooks, who
justified segregating people with preexisting conditions into underfunded
“high risk” pools (where they would likely be faced with staggeringly high
premiums, deductible and coverage limits) because, well, it’s the not the
responsibility of virtuous people to pay for the health care of people with
preexisting conditions who brought it on themselves:

“‘My understanding is that it will
allow insurance companies to require people who have higher health care costs
to contribute more to the insurance pool,’ said Brooks. ‘That helps offset all
these costs, thereby reducing the cost to those people who lead good lives,
they’re healthy, they’ve done the things to keep their bodies healthy. And
right now those are the people—who’ve done things the right way—that are seeing
their costs skyrocketing.’”

“I cannot adequately describe how much this enraged me” was
physician Aaron
Carroll’s poignant response to the “blame-the sick-for-being sick” meme, in
an essay I'm sick. It's not my fault. And I shouldn't have to pay more for my
health insurance he wrote for Vox.com.
Dr. Carroll recounts his own personal
experience with ulcerative colitis, a chronic condition he acquired through no
fault of his own, and raises important questions about the whole idea of
blaming people for being sick:

There is certainly a case to be
made that people have some responsibility for their health. But the lines
aren’t clear at all. It’s easy to point at smokers and say they’re doing
something harmful and are raising costs for all of us. That’s why we can charge
smokers more under the ACA. After that…it gets dicey.

Do you start regulating what people
eat? What they drink? If you eat dessert and I don’t, why should I have to pay
for your health care? Should we charge people more if they drive cars, which is
the number one killer of children? I like to ski. That has risks. So does rock
climbing. Or playing contact sports. Should we make them stop, or charge them
more? What about people who scuba dive?

Should we start charging more or
less to people who have different organs, whether that be male and female
reproductive organs or a spectrum of other differences in between?

Maybe the Congress member misspoke
and my interpretation of his words is off. But maybe not. Maybe he does believe
what he said, that people who did things the right way are the ones who are
healthy. If that’s the case, then I have a few questions for him.

What did the baby born prematurely,
the one with congenital heart disease, or the toddler with sickle cell disease,
or the child with autism, or the little girl with leukemia, or the boy with
asthma, or the adolescent with juvenile arthritis, or the young woman with lupus,
or the young man with testicular cancer, or the new mother with breast cancer,
or the new father with inflammatory bowel disease, or the woman with familial
heart disease, or the man with early onset Parkinson’s disease, or the retiring
woman with Alzheimer’s disease, or the elderly man with lymphoma — what did
they do wrong?

Did they lead bad lives?

Take your time answering. I’ll
wait.”

I share Dr. Carroll’s outrage, but would take it a step
further. Most of the examples he cites
above are people who are born with a disease, or acquire one through their
lifetimes that aren’t necessarily associated with any choices they made, like
breast cancer or Alzheimer’s. Or
voluntary choices, like playing a contact sport or skiing. While I agree with him that they should not
be charged more for their health care as a result, I am as concerned about
people who are sick with conditions that are associated with things they may or
may not have done to stay healthy, like having a poor diet that leads to
diabetes, or abusing drugs or alcohol (although I am sure that Dr. Carroll too
shares this broader concern).

For one thing, the idea that these are “lifestyle choices”,
freely made, is not correct; rather, the evidence suggests that they are due to
a confluence of hereditary and environmental factors, trauma, poor education,
income inequality and poverty, and other social determinants of health,
especially for the poor. As ACP
argues in a new position paper, Health and Public Policy to Facilitate Effective
Prevention and Treatment of Substance Use Disorders Involving Illicit and
Prescription Drugs, “Substance
use disorders have been regarded as a moral failing for centuries, a mindset
that has helped establish a harmful and persistent stigma affecting how the
medical community confronts addiction. We now know more about the nature of
addiction and how it affects brain function, which has led to broader
acceptance of the concept that substance use disorder is a disease, like
diabetes, that can be treated.” Many
people in poorer communities live in “food deserts” where access to healthful
diets is simply not available.

Of course, many well-off people also engage in activities
that may contribute to poor health—they may smoke, drive too fast, drink too
much, abuse other prescription and illicit drugs, not exercise regularly, and favor fast food over healthful
diets. The difference is that they can
usually afford good health care insurance and access to the best physicians and
hospitals when things go south. Not so
with the poor.

So the narrative that the undeserving sick don’t merit our help is really cut from the same
cloth as the undeserving poor
narrative: that some people, because they are sick and they are poor (which
often go hand-in-hand), don’t deserve compassion, and certainly don’t merit
financial help from those who are better off, money- or health-wise.

Growing up, I was taught that “There but for the grace of
God go I.” We should approach health
care policy in the same spirit, with the understanding that any one of us
could be poor or sick or both. We don’t have the right to selectively judge who “deserves”
health care, and to suggest otherwise is an outrage.

Today's question: what is your reaction to the undeserving sick narrative?

Thursday, April 27, 2017

It’s BACK—the terrible, horrible, no good, very bad bill to
repeal and replace the Affordable Care Act (ACA). Last month, I
blogged about how the bill, called the American Health Care Act, was the
worst legislation for health care of any that I have seen in 38 years of
advocacy for doctors and patients. While
it was good that this bill was pulled by House Speaker Paul Ryan on March 24
due to a lack of support among Republican
lawmakers, he may bring it back for a vote as early as this Friday, April 28.
Only, this time, believe it or not, with changes designed to win support from
hard-right conservatives that make the original bill even worse for
patients. I guess we will have to call
this version the even more terrible,
horrible, no good, very bad, bill for patient care.

On Tuesday, ACP was able to confirm that the House GOP
leadership and Trump administration were close to reaching a deal with 20 or so
of the most conservative lawmakers, the self-described “Freedom Caucus.”
Unfortunately, as explained in a
detailed letter that we sent to all members of Congress later that day, the
proposed “compromise” would gut existing
law protections for people with preexisting medical conditions and requirements
that insurers cover essential benefits by allowing states to opt-out of such
requirements. And today, we joined in a
coalition letter with 5 other physician membership organizations,
collectively representing over 560,000 physician and medical student members,
expressing our combined opposition to the “compromise” bill.

Let me be clear why the compromise makes a terrible bill
even worse:

It would allow states to obtain “waivers” to opt-out of the
ACA’s prohibition on insurers charging more to people with preexisting
conditions. That’s right, the
“compromise” would return us to the pre-ACA days when states often allowed
insurers to charge whatever they wanted to people with conditions like asthma,
diabetes or dozens of other conditions that were considered to be “declinable”
by insurers. As ACP explained in its letter to Congress, “Before the ACA, insurance plans sold in the individual
insurance market in all but five states typically maintained lists of so-called
"declinable" medical conditions—including asthma, diabetes,
arthritis, obesity, stroke, or pregnancy, or having been diagnosed with cancer
in the past 10 years. Even if a revised bill would not explicitly repeal the
current law’s guaranteed-issue requirement—which requires insurers to offer
coverage to persons with pre-existing conditions like these—guaranteed issue
without community rating allows insurers to charge as much as they believe a
patient’s treatment will cost. The result would be that many patients with
pre-existing conditions would be offered coverage that costs them thousands of
dollars more for the care that they need, and in the case of patients with
expensive conditions like cancer, even hundreds of thousands more.”

The bill does say that states would have to set up or participate
in high risk pools for people with preexisting conditions in order to be
approved for a waiver. But we know from
experience that underfunded high-risk pools, which were common before the ACA,
typically had very high premiums and deductibles, long wait lists, and limited
benefits, making the coverage unaffordable for those who need it most. And the
amended AHCA does not provide anywhere near the amount of money that could make
high risk pools viable, and does not set any standards or funding levels that
states must meet to ensure that coverage under the pools are affordable and
benefits are adequate.

It would allow states to obtain “waivers” to opt-out of the
ACA’s requirement that all insurers cover 10 categories of essential medical
care services. We know from the pre-ACA
days what this could mean for patients: in many states, insurers will once
again be allowed to decline coverage of needed benefits like physician and
hospital visits, maternity care and contraception, mental health and substance
use disorder treatments, preventive services, and prescription drugs. “Prior to
passage of the ACA, 62% of individual market enrollees did not have coverage of
maternity services, 34% did not have substance-use disorder services, 18% did
not have mental-health services and 9% did not have coverage for prescription
drugs,” ACP
wrote to Congress. “A recent
independent analysis found that the AHCA’s repeal of current law required
benefits would result in patients on average paying $1,952 more for cancer
drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung
diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient
admission for mental health; $4,555 for inpatient admission for substance use
treatment; and $8,501 for maternity care. Such increased costs would make it
practically impossible for many patients to avail themselves of the care they
need. The result will be delays in getting treatment until their illnesses
present at a more advanced, less treatable, and more expensive stage, or not
keeping up with life-saving medications prescribed by their physicians.”

And repeal of the essential benefit requirements would mean
that insurers would no longer be required to cover substance use disorder
treatments. “Allowing states to
eliminate the [Essential Health Benefits] will threaten our nation’s fight
against the opioid epidemic,” ACP told Congress. “A study concluded that with
repeal of the ACA, ‘approximately 1,253,000 people with serious mental
disorders and about 2.8 million Americans with a substance use disorder, of
whom about 222,000 have an opioid disorder, would lose some or all of their
insurance coverage.’”

And the “compromise” would even gut the ACA’s ban on
insurers imposing annual or lifetime limits on coverage, because under current
law insurers are only banned from imposing dollar limits on services that are
included in the mandatory essential health benefits package. If a state, for example, decided that
chemotherapy was no longer an essential benefit in your state, there would be
nothing stopping insurers from putting a $100,000 lifetime dollar limit (if
even that much) on coverage for your cancer treatment. After that, sorry, you’d be on your own,
forcing choices like lose your house, or lose your health care, you
decide.

The bill’s gutting of prohibition on annual and lifetime
coverage limits would affect not only people who get coverage through health plans sold through the ACA’s
marketplaces, but also the vast majority of people who get coverage from their
employer, as analyst Tim Jost explains today in a Health
Affairs blog. “Since the ACA’s
prohibitions of lifetime and annual limits and cap on out-of-pocket
expenditures also only apply to essential health benefits, states granted a
waiver would be able to define these protections as well. The changes to the
lifetime and annual limits and to the out-of-pocket caps could potentially
apply as well to large group and self-insured employer plans.” Jost also
observes that although the amendment says that “’nothing in this Act shall be
construed as permitting insurers to limit access to health coverage for
individuals with preexisting conditions,” but that is precisely what health
status underwriting [which could return in states that obtain waivers] does.
Health status underwriting could effectively make coverage completely
unaffordable to people with preexisting conditions.”

And remember, even before the proposed compromise made the
AHCA even worse, the original bill was unacceptable because it cut, capped, and
block granted Medicaid, ended funding for Medicaid expansion, and replaced the
ACA’s income-based premium and cost-sharing subsidies with regressive age-based
ones that would make premiums and deductibles unaffordable for older and sicker
patients, resulting in 24 million more uninsured persons, according to the
Congressional Budget Office.

So if politicians tell you that people with preexisting
conditions are protected by the amended AHCA, don’t believe them. They are either lying, or more charitably,
don’t understand what is being proposed.
And if they say premiums will be lower, keep in mind that while this
might be true for some young and healthy people, it would be at the expense of
making health care unaffordable for older and sicker patients.

Yet Speaker Ryan is counting votes right now in the hope of
bringing the bill to a vote by Friday so it can be passed by the House of
Representatives during President Trump’s first 100 days.

Don’t let Speaker Ryan and President Trump bring their even
more terrible, horrible, no good, very bad bill back from the dead. Call your member of Congress today,
especially if he or she is a moderate
Republican or one in a competitive district, at 202-224-3121 and help us
put a nail in the AHCA’s coffin. (And
even if you have called before, they need to hear from you again). Don't put this off, tomorrow could be too
late. Patients are depending on you.

Today’s question: did you make your call to Congress to urge
them to vote no on the even more terrible, horrible, no good, very bad AHCA!

Thursday, March 23, 2017

When
I tweeted
this on Monday morning about the House GOP bill to “repeal and replace” the
Affordable Care Act, I had no idea that it would result in me appearing on
MSNBC’s Last Word with Lawrence O’Donnell or that it and my other tweets would be referenced by NBC News, a New York Times editorial, or for that matter, a retweet from singer-songwriter John Legend!

I mention all of this not for reasons of self-promotion, but
to share with readers of this blog why I firmly believe that the GOP “repeal
and replace” bill, expected to be voted on later today in the House of
Representatives, will, if enacted, do more harm to health than any I have seen
in nearly four decades of advocacy on behalf of internal medicine.

Here are my reasons:

First, never before I
have I seen legislation advanced to the floor of either the House or Senate
that would take health insurance coverage and consumer protections away from
tens of millions of Americans; not once, not ever. In fact, I doubt there is any time in history
where Congress is being asked to vote to take health care away from so
many. Instead, the trajectory has been
to expand health insurance coverage,
not take it away: from enactment of Medicare and Medicaid in 1965, to the
bipartisan Children’s Health Insurance Program becoming law in 1997; to
creation of the Medicare Part D prescription drug program, signed into law by
President George W. Bush on December 8, 2003; to the Affordable Care Act becoming
law on March 23, 2010, exactly seven years ago. Up until now, no President of either
political party, and no Congress, has championed a measure that would result in
a wholesale rollback of coverage and access to care for people who have gained
it under prior laws.

Second, and most
importantly, the American Health Care Act would do incalculable harm to the
health of tens of millions of Americans.
This is not a political assessment, it’s based on what the bill
actually proposes to do and evidence (from independent and non-partisan
researchers) on how patients will be affected.

It makes radical
changes to the Medicaid program’s structure and financing; the non-partisan
Congressional Budget Office (CBO) estimates
that 14 million low-income kids, adolescents and adults will lose their
Medicaid coverage as a result. By putting a per-enrollee cap on the federal
contribution to Medicaid, or offering states a “block grant” option (both of
which means that the states are left having to make up any difference between the
federal contribution and the costs of providing benefits to Medical enrollees),
and phasing out the higher federal contribution for states that have expanded
Medicaid to persons with incomes up to 138% of the Federal Poverty Level (FPL),
the CBO found that the total federal contribution would be cut by $890 billion
over the next decade, a whopping 25% cut!
Because
most states are required by law to balance their budgets, a reduction in and/or
a cap on federal matching funds will necessarily require them to greatly reduce
benefits and eligibility and/or impose higher cost-sharing for Medicaid
enrollees, most of whom cannot afford to pay more out of pocket—or
alternatively and concurrently, reduce payments to physicians and hospitals
(including rural hospitals that may be forced to close), enact harmful cuts to
other state programs or raise taxes. The
phase-out of funding for Medicaid expansion, and the retroactive (to March 1)
freeze on providing enhanced funding to any additional states that might have
expanded the program, will eliminate one of the most effective programs ever in
driving down the uninsured rate to historic lows. Some Republicans surely recognize the
importance of preserving funding for Medicaid expansion in their states: just
yesterday, Michigan (GOP) Governor Rick Snyder wrote
to the state’s congressional delegation urging them to vote against the AHCA.

It would reward states with higher federal
funding if they impose punitive work or job search requirements on certain
Medicaid enrollees. If states adopt such requirements, current
Medicaid enrollees (or those seeking to enroll) would not be eligible for the
program if they are unable to prove to state Medicaid officials they have a job
or are in job-training, or that they meet the conditions specified in the
statute to be exempted from the requirement. Medicaid is not a cash assistance or job
training program; it is a health insurance program and eligibility should not
be contingent on whether or not an individual is employed or looking for work. While an estimated 80% of Medicaid enrollees
are working, or are in working families, there are some who are unable to be
employed because they have behavioral and mental health conditions, suffer from
substance use disorders, are caregivers for family members, do not have the
skills required to fill available positions, or there simply are no suitable
jobs available to them. Skills- or
interview-training initiatives, if implemented for the Medicaid population,
should be voluntary, not mandatory. ACP’s
Ethics, Professionalism and Human Rights Committee has stated that it is
contrary to the medical profession’s commitment to patient advocacy to accept
punitive measures, such as work requirements, that would deny access to
coverage for people who need it.

Although not final, it’s been widely reported
that Speaker of the House Paul Ryan will add to the version of the bill being
voted on today a repeal of the ACA requirement that private insurers in the
individual insurance market must cover 10 categories of essential services
including physician and hospital visits, prescription drugs, cancer screening
tests and other preventive services, mental health treatment, and many other
services.
Even before this change, the AHCA repeals the requirement that Medicaid
programs cover such benefits. Any
reduction in Medicaid coverage for substance use disorder treatments would
exacerbate the grave opioid misuse epidemic that is devastating individuals,
families and communities across the country.
Women’s access to health care would particularly be at risk, because the
AHCA eliminates required coverage for childbirth and maternity and for
contraception.

Prior to passage of the ACA, 62% of individual
market enrollees did not have coverage of maternity services, 34% did not have
substance use disorder services, 18% did not have mental health services and 9%
did not have coverage for prescription drugs. A recent independent analysis
found that the AHCA’s repeal of current law
required benefits would result in patients on average paying $1,952 for cancer
drugs; $1,807 for drugs for heart disease; $1,127 for drugs to treat lung
diseases; $1,607 for drugs to treat mental illnesses; $4,940 for inpatient
admission for mental health; $4,555 for inpatient admission for substance use
treatment; and $8,501 for maternity care.
Such increased costs would make it practically impossible for many
patients to avail themselves of the care they need. The result will be delays in getting
treatment until their illnesses present at a more advanced, less treatable, and
more expensive stage, or not keeping up with life-saving medications prescribed
by their physicians.

The AHCA’s regressive age-based tax credits,
combined with changes that will allow insurers to charge older people much
higher premiums than allowed under current law, will make coverage unaffordable
for poorer, sicker, and older persons, as well as for persons who live in high
health care cost regions. The AHCA
replaces the ACA’s income-based and cost-sharing subsidies with age-based
advance refundable tax credits worth only $2,000 to $4,000 for an
individual. These subsidies will be
inadequate for most people to be able to buy affordable coverage, and would
especially put vulnerable persons at risk, including low-income families and
children, children and adults with special health care needs, and older persons
with chronic illnesses who are not yet eligible for Medicare. Indeed, a
study based on the value of these tax credits determined that only 34% of a beneficiary’s medical costs would be covered. This is much less
than the ACA, which ranges from about 60% to 94%, depending on the level of
plan. By repealing the current law cost-sharing subsidies for persons with
incomes up to 250% of the FPL, the AHCA would make out-of-pocket costs too
high, and health care unaffordable, for many poorer patients. Without
cost-sharing reductions, enrollees will be exposed to higher deductibles,
co-payments and other cost sharing, potentially discouraging patients with
limited financial means from seeking medically necessary care. The AHCA also establishes a set amount for
the tax credits per individual, without any adjustment for differences in the
cost of care by locality. This will
result in the tax credits being insufficient to make coverage affordable for
patients in high health care cost areas, especially older, poorer and sicker ones.

The AHCA discriminates in the awarding of
federal grant funds and/or Medicaid and Children’s Health Insurance Program
funding to women’s health clinics that are qualified under existing federal law
for the provision of evidence‐based services including, but not limited to,
provision of contraception, preventive health screenings, sexually transmitted
infection testing and treatment, vaccines, counseling, rehabilitation, and
referrals.
This provision, targeted at Planned Parenthood, reduces women’s access
to evidence‐based services offered through the clinics including, but not
limited to, provision of contraception, preventive health screenings, sexually
transmitted infection testing and treatment, vaccines, counseling,
rehabilitation, and referrals.

The AHCA eliminates funding for Prevention and
Public Health Fund, which provides billions in dollars to the Centers for
Disease Control and Prevention to prevent and control the spread of infectious
diseases like flu, Zika, and epidemics and pandemics.

I could go on and on with other reasons why
Congress should vote down the American Health Care Act but I think (hope) you
get the point: this bill is a monstrous and unprecedented assault on coverage
and access to care for many millions of Americans, and especially, the most
vulnerable of our neighbors: those who are older, poorer and sicker. It is by far the worst piece of
health-related legislation I have seen since I first started working for the
American Society of Internal Medicine (which merged with ACP in 1998) when
Jimmy Carter was president. It must be
stopped, now.

Today’s questions: What do you think of the
AHCA, and what are you doing about it?

Wednesday, February 22, 2017

President Trump argues through his Twitter posts that his
administration’s travel ban on immigrants and refugees from 7 majority-Muslim
countries, currently on hold because of court rulings against it, is about
keeping “bad people” out of the country.
Commenting on the initial ruling by a federal judge suspending the ban,
which was then upheld by a 10-1 ruling by a federal appeals court, President
Trump tweeted:

“The judge opens up our country to potential terrorists and
others that do not have our best interests at heart. Bad people are very
happy!”

“Because the ban was lifted by a judge, many very bad and
dangerous people may be pouring into our country. A terrible decision.”

“What is our country coming to when a judge can halt a
Homeland Security travel ban and anyone, even with bad intentions, can come
into U.S.?”

Rather than continuing to fight it out in court, though, the
administration has announced that it will issue a revised executive order this
week, one that it believes will pass muster with the courts. We will see what
the new order says and if the courts agree.

From the standpoint of what’s best for health care, though,
ACP believes that it is essential that the revised order discontinue the policy
of discriminating against foreign-born physicians and medical students,
especially Muslims, from the 7 designated countries, and thousands of refugees
from them seeking shelter in the United States.

The fact is that rather than keeping out “bad people” who
want to do us harm, President Trump’s executive order denied travel to many
physicians who live in the United States with valid visas, physicians who
provide care to hundreds of thousands of patients. Among them are:

Dr. M. Ihsan Kaadan, a Syrian doctor who treated patients
suffering from the horrors inflicted on the civilians of Aleppo, Syria; he
later was granted a visa to enter the United States to continue his
studies at Brandeis and his internal medicine residency training at
Massachusetts General. “In hopes that
leaders and politicians around the world reconsider any plans to ban refugees
who seek to escape brutal wars and other human tragedies” Dr. Kaadan recently
wrote of his experiences:

“I am a Muslim and I am from Syria,
I came here fleeing a brutal war that has killed more than 400,000 men, women, and children. I have
the features that make me look like what some people think of as terrorist. But
I am not a terrorist. In fact, I’m the opposite — I am a patriot for America
and for Syria. I want to serve the country that opened its doors to me and also
help my home country.”

President Trump, Is Dr. Kaadan among the “bad people” you
want to keep out?

Drs. Kaadan and Berzing are hardly alone. There are 15,000
physicians from across the United States that are from the 7 countries
subject to the travel ban, many of whom are providing care to Americans in
underserved communities. Even if the
executive order would allow them to remain in the U.S. as long as they had
valid visas, the travel ban placed them at risk of not being able to reenter
the U.S. if they traveled home to see their families—say to see an ailing aged
parent. In fact, there were at least three physicians in U.S. internal medicine
residency programs, ACP members,
who were traveling abroad at the time the executive order was issued and were
turned away from re-entering the United States. And, according to the
Association of American Medical Colleges, there are currently 260 applicants
from the affected countries among the 35,000 people seeking residency and
fellowship positions in this country.

President Trump, are these 15,000 physicians seeking to
train in the U.S. and provide care to the most underserved Americans among the “bad
people” you want to keep out?

President Trump, are these children among the “bad people”
you want to keep out?

The American College of Physicians has taken
a firm stance against discrimination in immigration policy based on
religion and in
strong opposition to the President’s executive order, and in
support of comprehensive policies to reform immigration laws and policies
to allow physicians and medical students with approved visas to travel freely
to and from the United States, to protect “Dreamers” from deportation, and to
expand the number of refugees accepted into the United States, particularly
those with urgent medical needs. We have also joined
with 11 other internal medicine membership organizations to urge the
Department of Homeland Security to immediately implement changes to lift
restrictions on travel for physicians and medical students with approved visas
and to prioritize admitting refugees who need medical care.

The Trump administration still has a chance to get things
right this time in its revised executive order, by lifting discriminatory
travel restrictions on Muslim physicians and medical students and refugees who
have been thoroughly vetted and approved for visas to travel to and from the
United States. Let’s hope it does,
because maintaining the current policy in some other form is bad for health
care, bad for medical education, and bad for the millions of patients who get
their care from foreign-born physicians—and for many refugees, it’s a matter
of life and death.

Today's question: What do you think of President Trump's travel and immigration ban and ACP's advocacy to overturn it?